respirationrespiration elisa a. mancuso rnc, ms, fns professor of nursing
TRANSCRIPT
RespirationRespirationRespirationRespiration
Elisa A. Mancuso RNC, MS, FNSElisa A. Mancuso RNC, MS, FNS
Professor of NursingProfessor of Nursing
Respiratory Alterations • ↑ Risk < 3 years
Smaller upper and lower airways Underdeveloped supporting cartilage
ineffective clearing of organisms Immature immune systems
Compensatory Mechanisms• Lungs- ↑ or ↓ RR• Kidneys- retain or filter H+ affects pH
Blood buffer system: H+, HgB, Na
Interact to maintain pH
Interpreting ABG’s
• Know your normal values!• PH 7.35-7.45
< 7.35 = Acidosis > 7.45 = Alkalosis
• PaCo2 35-45< 35 = Alkalosis > 45 = Acidosis
• HCO3 22-26< 22 = Acidosis > 26 = Alkalosis
PaO2 90-100% < 90 = Hypoxia
Respiratory or Metabolic?
ROME Respiratory opposite (pH & CO2)Metabolic even (pH & HCO3)
Respiratory reflects PaCO2 ↓ CO2 = alkalosis↑ CO2 = acidosis
Metabolic reflects HCO3 and BE ↓ HCO3 = acidosis↑ HCO3 = alkalosis
Respiratory Alterations
Respiratory Acidosis• ↓ PH and ↑ PaCO2• Causes
– ↓ RR– Neuromuscular problems: BPD,
RDS, CF• Respiratory depression and ↑ CO2
Respiratory Alkalosis• ↑ PH and ↓ PaCO2• Causes– ↑ RR ↑ Fever Stress
Metabolic Alterations
Metabolic Acidosis • ↓ PH and ↓ HCO3• Causes
– Renal failure, diarrhea, ketoacidosis
Metabolic Alkalosis • ↑ High PH and ↑ HCO3• Causes
– Vomiting, Meds for ulcers, NaHCO3, – NGT = HCL loss & ↑ HCO3 – Diuresis
Case Study Mariska, 4 years old presents with
following: RR = 54 C/O Chest tightnessBilateral expiratory & inspiratory wheezingFrightened appearance.ABG pH of 7.27, PaO2 88, PaCO2 48 and
HCO3 24.
What is her acid – base status?• Identify each component. • Find the cause• Answer????
Upper Respiratory Infections
URIAcute pharyngitis and
nasopharyngitis• Children get 7-10 colds/year!• Majority is viral = Rhinovirus
Signs and symptoms• low grade fever • sore throat • spontaneous recovery
– Self limiting 7-10 days
URIs Bacterial• Group A beta-hemolytic strep
(GABHS)Signs and symptoms• Abrupt onset• Fever >102, chills • Fatigue, HA• Nasal congestion• Abdominal pain & Anorexia • Vomiting, diarrhea• Halitosis • Fire red throat & petechiae • Exudative
Treatment of Strep Pharyngitis
• Throat culture IN and OUT. – Rapid antigen detection test 60-95%
sensitive.
• Antibiotics Prevents serious complication = Rheumatic
feverPEN-VK BID-TID drug of choice x 10 days• Amoxicillin 40-45mg/kg/day ÷ BID – ↑ tasting and ↓ dosing needed– ↑better compliance!
• Zithromax 10mg/kg/day 1 – 5mg/kg day 2-5
• Cefdinir (Omnicef) 14 mg/kg/day• Cefixine (Suprax) 8mg/kg/day
Treatment (cont)• Bed rest• Tylenol 10-15mg/kg every 4 hours
– √ Infant vs. Child concentration!
• Saline gtts and cool mist humidifier• Hydration • Decongestants > 6 months.• Contagious: Separate from others!
– Need meds x 24 hours – Then return to school– Feel better in 24-48 hours!– Must Complete all meds!
Tonsils• Lymphoid tissue in pharyngeal cavity• Filter and protect respiratory and GI
tract• ↑ Antibody formation
– until 3 years & immune system mature
• ↑ ↑ size in children until puberty• Inflamed with infections• If chronically enlarged 3+ → 4+
– Obstructive Sleep Apnea (OSA)– Difficulty breathing and eating
Tonsillitis
• Persistent cough • Dry mucous membranes• White patchy exudate• Secondary OM from blocked
Eustachian tubes• Viral-
Self- limiting
• Palliative measures• Pain & Hydration
Tonsillectomy• Most common indication today is OSA• 4 strep infections/season• Peri-tonsilar Abscess Post-op care• ↑ HOB with pt prone or on side• Encourage fluids PO -No straws!• Medicate for pain (no ASA) and N/V• Ice pack to anterior neck√ Hemorrhage (5-20%) Go to OR!• (1st 48 hours and then 5-7 days)• ↑ ↑ swallowing/vomiting bright red blood• ↑↑ RR ↑↑ HR ↑↑ Restlessness
Normal Eschar forms
Epiglottitis
• Medical Emergency – ↑ @ 3-6 years
• Haemophilus influenza type B (HIB) (50% pre-vaccination)– Dramatic ↓↓ since HIB vaccine
• Strep pneumoniae, staph aureous.• Rapid & severe inflammation
– of epiglottis and surrounding areas
– Complete airway obstruction
Signs and symptoms• Abrupt onset of sore throat• Fever 102-104 - toxic appearing• 4 D’s
– Dysphonia (muffled voice)– Dysphagia (↓ swallowing)– Drooling– Distress/Dyspnea
• Inspiratory stridor• Retractions ↑ RR ↑HR Pallor• Tripod position Thumb sign
on soft tissue x-ray
TreatmentMEDICAL EMERGENCY: ANESTHISIA STAT!!• DO NOT INSPECT THROAT!• LIMIT UPSETING PROCEDURES!• Establish Airway• Respiratory Isolation!• Humidified O2• Hydration
• Antibiotics (Meningitic doses)– Ampicillin 200-400 mg/kg/day ÷ q6H– Chloramphenicol 75-100mg/kg/day ÷ q6H
• Steroids– Methylprednisolone 2mg/kg/day ÷ q6H
CroupLaryngotracheobronchi
tis
• Acute spasmodic laryngitis – Upper airway
• ↑ 3 months to 5 years– peak @ 2 years
• Paroxysmal laryngeal edema– Attacks @ night
• Parainfluenza virus or allergic reaction• ↑ in fall and winter months• Precipitated with nasopharyngitis
Clinical signs• Awakes suddenly with barking cough • Inspiratory stridor• Hoarseness• Restlessness• Anxious• Retractions, ↓↓O2 • Stridor @ rest = severe croup• ↑ Temp 101-102• Duration few hours, Repeat x 2 nights• Symptoms improve with change in
temp
Treatment• Maintain airway• Position upright• Cool mist humidified O2• Steam shower or expose to cold night
air• Decadron 0.6mg/kg IM/PO x 1 dose• Racemic epinephrine 2.25% nebulizer
– for inspiratory stridor at rest
• Induce vomiting = stops laryngospasm• Hospitalize only when:
– ↑ Stridor ↓ O2 ↓LOC
Otitis Media (OM)• Acute inflammation & effusion of middle
ear
Common pathogens • Strep pneumonia (50%)
– ↓ incidence with Prevnar vaccine
• Haemophilus influenza (30%)-not type B!• Moraxella catarrhalis (20%)
– ↑↑ incidence with resistance
• Viruses • Food Allergies
PathophysiologyEustachian tube dysfunction • < 5 years = shorter, wider and straighter• Acute
– bacteria/purulent exudates
Signs and symptoms• ↑ ↑ Pain, ↑ ↑ irritability• Tugging on ears• Fever >102• Rhinorrhea, cough and congestion• Anorexia, vomiting and diarrhea• Tympanic membrane
Red & bulging
Tympanogram No movement of TM Hearing loss
To treat or not treat?
AAP guidelines to ↓ resistant organisms • < 6 months:
– with S/S of illness → Treat!
• 6 mos -2 years: – certain diagnosis → Treat!– Uncertain & no s/s of severe illness = Observe
• > 2 years: – certain diagnosis & no S/S of severe illness – Observation & Pain Relief
AMERICAN ACADEMY OF PEDIATRICS, Guidelines for Acute Otitis Media,
2004
Treatments
• Amoxicillin 40-45mg/kg/day ÷ BID– Now recommending high dose:
– 80mg/kg- 90mg/kg/day ÷ BID
• Augmentin 40-45mg/kg/day BID for resistance to amoxicillin
• Ceclor 40 mg/kg/day• Bactrim/Septra 8mg/kg/day • Rocephin for resistant OM’s Myringotomy Tubes
Frequent infections Prolonged fluid
Bronchiolitis (RSV)Disease of lower airways • Respiratory syncytial virus (RSV) = common
cause• Can be fatal in <2 months/premature• 90% of infants <1 year get RSV• ↑ incidence winter/spring• ↑ Contagious via direct contact & inhalation
– Use alcohol based hand rubs.
Pathophysiology• RSV affects epithelia cells of lungs• Bronchioles become edematous• Lumen filled with mucous - green thick
exudate • Bronchioles infiltrated with inflammatory cells
– Air trapping• Severe cases mucous plugging & apnea=
death
RSV Clinical signs• Nasal Aspirate Culture =
– (+) ELISA • enzyme-linked immunosuppressive assay
– (+) RSV Ag or rapid fluorescent antibody• Peak @ 72 hours after onset• Rhinorrhea with thick, tenacious, green
secretions• RR, retractions & cyanosis• Coughing, wheezing• CXR
– Hyperinflation (obstructive emphysema)– Atelectasis =↓ Breath sounds (PN)
• Hypoxia → apnea and even death
Therapy• Respiratory Isolation• Cool mist humidified O2
– √ O2 sats! >95% is nl• ↑ Hydration• Antibiotics for PN• Bronchodilators• Steroids• Severe Cases
– Racemic epinephrine – Mechanical ventilation
Prophylactic Approach• Respi Gam (RSV Immune Globulin) $600/vial• Synagis (Monoclonal AB) 15 mg/kg IM
– Binds with RSV to ↓ infection. – @ beginning of RSV season Oct - Nov– total of 5 monthly doses; Need ↑ titers to be
effective
Asthma
• Inflammation & Hyperactivity• Abrupt onset after URI or allergen• RAD= Reactive Airway Disease
– Reversible bronchospasm
• 8 million kids/year • 1st attack usually @ 3-8 years
Pathophysiology• Inflammation
– Histamine release to allergen/trigger (stimulus).– Edema→ Mucous Production → Bronchial Obstruction &
Spasm• Bronchoconstriction
– Hyper-responsiveness of stimuli:• Allergens:
– Cigarette smoke Dust mitesExercise
– Cold air Stress Drugs (ASA/NSAID) • • Urban factors:
– #1 Cockroach droppings– Diesel fumes
Early & Subtle Clinical signs
• Irritable• Itchy• Tired• Dry mouth• Dark circle under eyes• Chronic cough worse @ night
Clinical Signs Older child
• SOB and Dyspnea• Expiratory wheeze bilaterally• Chest pain or tightness → ↑ HR• Spasmodic or tight cough @
night• Abdominal pain and nausea• Mild Intermittent
– <2 days/week• Severe Persistent
– Constant/daily
Warning signs
• Retractions ↑ RR and Hypoxia<92% (Admit to hospital)
• As symptoms progress → – Expiratory & Inspiratory wheeze
• ↑ HR• Breathlessness • Anxious & Restless• Absent breath sounds
– No air movement – Respiratory arrest!
Status Asthmaticus• Limited or no response to therapy• Respiratory distress → arrest• ICU
– IV Hydration & Intubation
• Medications:– Steroids – Magnesium Sulfate IV – Bronchodilators Nebulizer RX– Antibiotics
Diagnostic Tests
• Allergy testing- – 4-8% have a food allergy
• Pulmonary Function Test (PFT)– Forced exhalation– √ before and after neb – Reliable when
•age > 5 years •good effort
Peak Expiratory Flow Rate (PEFR)
• Assess asymptomatic lung changes and function.
• Based on child’s height Ex: 47”=PEFR=200
• Peak flow zones – Visual = ↑ manage – Early interventions– Maintain control
Asthma Therapy
The National Asthma Education and Prevention Program (NAEPP) 2002
4 components of asthma management:
• Measures of assessment and monitoring
• Control factors that contribute to severity
• Education for a partnership in asthma• Pharmacologic therapy
Bronchodilators “Rescue meds”
Inhaled Beta 2 AgonistsAlbuterol (Proventil,Ventolin) 0.15-5 mg/kg/doseLevalbuterol (Zopenex) > 6 years 0.31mg/kg/dose SE = Tremors ↑ HR Hyperactivity
Bronchospasm = Overdose!
• AnticholinergicIpratropium (Atrovent) MDI 1-2 puffs q6-8HSE = Dizzyness HA Cough ↓ BP
• Methylzanthines Theophylline (PO) Aminophylline (IV) √ serum levels (10-20) SE = ↑ HR Arrhythmias
Systemic B2 agonists SC Epinephrine 1:1000=bronchodilation x 3doses Caution CARDIAC DOSE 1:10,000 SE = ↑ BP ↑ HR Tremors
Terbutaline (Brethine) SQ/IV SE = Restlessness cardiac arrthymias Stops pre-term
labor
Anti-Inflammatory medsSystemic Corticosteroids• onset - 3 H Peaks in 6-12 H• Loading dose 2mg/kg and taper slowly• No need to taper if short term use
Short-Acting (use 5-7 days ↓ SE)• Hydrocortisone (Solu-Cortef) 0.25-2 mg/kg/day• Methylprednisolone (Solu-Medrol) 1-2 mg/kg/dose• Prednisone PO 1-2 mg/kg/dose• Prednisolone (Orapred, Pediapred) PO 1-2 mg/kg• Dexamethasone (Decadron) 0.6-1.5 mg/kg/day
• SE = Hyperglycemia GI distress ↓ Growth
Cushing Syndrome = ↑ Wt. ↑ Infection Mood Lability
Controller MedsInhaled corticosteroids- Not rescue drug • Budesonide (Pulmicort) 2-4 puffs tid• Fluticasone (Flovent)• Triamcinolone (Azmacort, Kenalog)• Advair discus
– Synergistic effect with B2agonists– SE = Oral & pharyngeal irritation
Non-steroidals- • Cromolyn Na (Intal)
– Stabilizes mast cells & prevents attack.• Leukotriene Receptor Antagonists-(LRA)
– Leukotrienes cause inflammation (capillary permeability)
– Use at night when leukotrienes are highest.– Montelukast (Singulair) 5-10 mg PO/day– Zafirlukast (Accolate) 10-20 mg PO/day– Zileuton (Zyflo) 300-600 mg PO/day
SE = HA Vasculitis Flu like symptoms
Other Treatments• ↑ Fluids
– Dilute mucous & mobilize secretions
• May need allergy shots• Zyrtec or Clarinex =↓ allergy
symptoms. Singulair now indicated for allergy use as well as asthma maintenance
• Nasal Lavage • Treat cold symptoms>7-10 days
– 60-80% pt with allergic asthma have – sinusitis
Parent Teaching• Remove allergens
– Identify precipitating factors– ↓ Rugs, heavy drapes, pets, foods (eggs,
milk)– Mattress & pillow covers
• Dehumidifier - AC• Review
– Signs/symptoms of asthma– PEAK Flow daily– Meds SE & toxicity– Nebulizer use
• ↓ Antihistamines – May exacerbate wheezing
• Swimming = Best Exercise
Cystic FibrosisDysfunction of exocrine glands
– ↑↑ Na++ ↑ Cl- in sweat & saliva – (2- 5x normal levels)– ↑↑ Viscosity of secretions– GI & Pulmonary systems
Autosommial Recessive – 1/25 whites carry gene.
•Chromosome # 7•CC = Healthy•Cf = Carrier•ff = Disease
• 25% risk = healthy/disease• 50% risk = carrier
Mom→Dad ↓
C f
C CC Cf
f Cf ff
PathophysiologyPulmonary• ↑ Leukocyte DNA in sputum
– Long, thick strands
• ↑↑ Thick mucous (yellow/grey)• ↓↓ Diffusion of gases → ↓ O2 hypoxia ↑ CO2• ↑↑ Respiratory distress & Pseudomonas PN• Obstruction =
– Fibrotic and stiff lobes– ↓ compliancy & ↓ function
Pancreas• Thick secretions block ducts • Fibrosis = ↓↓ pancreatic enzymes
• Malabsorption Syndrome – Only 50% of food is absorbed– Inability to digest & absorb proteins &
fats – “Steatorrhea” foul smelling bulky
stools– ↓↓ fat soluble vitamins A,D,E and K.
• Bile ducts – Occluded: biliary cirrhosis & portal ↑
BP
Hallmark – CF Signs
• Meconium Ileus (newborn) – No mec passed in 1st 24 hours– Abdominal distention– 10-15% & 1st sign of CF
• Skin - “Infant tastes salty”– Sweat Test (Pilocarpine
Ionophoresis)– > 1 month old– Cl> 60 mEq = (+) CF
Respiratory Signs
• Frequent sinus & respiratory infections.
• Bronchitis & PN• Recurrent pneumothorax• SOB, wheezing, hemoptysis• Dyspnea, Hypoxemia• Barrel shaped chest
– AP>lateral
• Clubbed fingers
Gastrointestinal Signs• Steatorrhea
– Excretion of undigested fats and proteins– Bulky, frothy, foul smelling stool
• Abdominal Distension – 3rd spacing & edema RT ↓↓ protein & albumin
• Prolapsed rectum• Voracious appetite RT starving
– only 50% of food absorbed
• Failure to thrive – ↓↓ drop on growth chart 10-25% = short
stature
Diagnosis• Genetic testing
– DNA analysis: Chromosome # 7– Prenatal screen (↑↑mutations exist)– F508 mutation in 70% of pt with CF
• Sweat Test– Cl>60meq strongly suggests CF
• Stool specimen– 5 day collection √ fat content
• Duodenal Enzymes– ↓↓ trypsin and chymotrypsin – (absent in 80% of CF pt’s)– Immunoreactive Trypsin Test
• >140 = CF (+)
Therapy• Goals
– ↑ Life Expectancy > 30– ↑ Quality of life– ↓ Sequella of CF
• Nutrition – ↑ protein ↑ calories and moderate fat– Need 150% of daily requirements to replace
losses– ↑ Na intake in hot weather
• MedicationsPancrelipase (Pancrease, Pancrease MT4) PO– (10,000u lipase/36,000u protease & amylase)– Enteric coated & must give before all meals!– ↑ digestion of fats, proteins and carbs. – SE: diarrhea and abdominal cramping
Therapy • Supplements
– Fat Soluble Vitamins• A, D, E & K (2x dose)
– H2O Soluble Vitamins• C, B, B2, B6 (B-C complex)• Niacin, B12, Folic Acid
• Pulmonary-– 1st Assess breath sounds and O2!– Nebulizer treatments then PD & C. – CPT x 15-20 minutes in trendelenburg. – Vibrate all lung fields =mobilize
secretions
Inhalation Therapy• Dornase Alfa-Pulmozyme
– Recombinant DNAse 2.5 mg– Breaks down DNA in sputum – ↓↓ viscosity of sputum– SE- laryngitis– Administer via neb before PD&C
• Proventil • Thoracic expansion exercises
– Stretching & Breathing– Swimming (↑ mobility)
Family Support• Educate
– Disease process and S/S of illness– Meds and diet
• Pulmonary care ATC – Need ↑ support group to assist q 3-4 H– Breathing exercises– Antibiotics only for documented
infections!• Encourage verbalization of fears
– Numerous Hospitalizations– Invasive Procedures (CT) lung transplants– Anticipatory Grieving -Fatal Illness– Support group
• CF Foundation• www.cff.org www.cysticfibrosis.com
Foreign Body Aspiration↑ Risk @ 1-3 years of age
– Developmental stage ↑ curious and – hand–to-mouth or nose– 4th cause of accidental death < 5 years– Acute and dramatic onset
Common Objects• Small toys• Buttons• Paper clips• Batteries (Acid leaks = chemical PN)• Food• ↑ in size as absorbs H2O
– ↑ Edema = ↑ Obstruction– Hotdogs Grapes Nuts Seeds
Clinical SignsLaryngeal• Choking & Coughing • Aphonia = No cry or speaking• Rapid color change → blue• Inspiratory stridor• ↓ O2 → Change in LOC → Collapse/Unconscious
Bronchial# 1 site = R main stem bronchus• Wheezing Lung• Persistent respiratory infections
– Cough & congestion– Purulent secretions– Foul smelling breath
• Acute or chronic pulmonary lesions
Interventions• Immediate Intervention (Death in 4 mins!)
• CPR – Obstructed Airway– Infants-
• alternate 5 back blows with 5 chest thrusts – Kids >1 year
• Heimlich• CXR
– Identify object & location • Bronchoscopy
– Removal of object ASAP!• Post removal
– Humidity– Steroids
• ↓ Edema & ↓ inflammation – Antibiotics
Pneumonia• Classified according to agent or location:
– Viral (RSV) most common – Bacterial (strep pneumoniae, pseudomonas)– Fungal (candida)– Chemical/Aspiration (Oil, lotion, cleaners)
Pathophysiology• Inflammation of lung parenchyma• Consolidation - aveoli fill with exudate • Bronchial Obstruction
– RT ↑ restriction of lung – ↓ Impaired gas exchange ↓O2 & ↑ CO2
Primary Atypical Pneumonia
Mycoplasma pneumoniae• Most common pathogen in
older children 5-12 years of age
• ↑ incidence in Fall and Winter• ↑ Highly populated areas• Diagnosis:
– CBC & Differential– BC or Tracheal aspirate– CXR– ELISA test
Clinical signs• Sudden or gradual onset
– could be a 7-10 day duration of symptoms• Fever - low grade• Chest pain• Flushed cheeks with generalized pallor• Hacking cough• Pharyngitis• Coarse Crackles or rhonchi• ↓ Breath sounds with dullness
(consolidation)• Hypoxemia • Anorexia• Malaise
Therapy• O2 √ Pulse oximeter• ↑↑ Hydration PO/IV• Humidity• CPT
– Blow Bubbles• ↑↑ HOB & RestMedications• Azithromycin (Z-Pack)
(10 mg/kg day 1 then 5 mg/kg day 2-5)• Erythromycin
30-50 mg/kg/day PO/IV ÷ q 6-8 x 14 -21 days No IM causes tissue necrosis!
• Acetaminophen (Tylenol)– 10-15 mg/kg/dose √ (infant vs. children)– ↓ Pain & Fever
• Expectorants only No cough suppressant!
Bacterial Pneumonia• ↑ Risk @ birth-5 years• Strep pneumoniae (90%)
Clinical signs/symptoms• Abrupt onset after viral illness - URI
– ↓↓ immune system• High fever 104-105• Retractions, tachypnea, hypoxia• Rales/rhonchi• Chest Pain with deep inhalation
– Pleural effusion→ Shallow respirations & ↑ CO2
• Abdominal pain– Lower lobe infiltrate
Therapy• Similar to Mycoplasma• Maintain patent airway!• Isolate with same pt if hospitalized• Lying on affected side ↓ pleural rub/pain• CT for thoracentesis
Medications• Antibiotics- appropriate drug for the bug!
– High dose Amoxicillin or Augmentin (40mg/kg/day PO)
– Ceftriaxone (Rocephin) (50-75 mg/kg/day)• ↑ WBC or based on S/S
– Cefotaxime (Claforan) 100-200 mg/kg/day– Ceftiazidine (Fortaz) 150 mg/kg/day
• Tylenol• Expectorants